Carballo-Diéguez

times Hispanics drift to underemployment because of overt racism and discrimination. Gay Hispanics are often subject to double discrimination: That of society in general toward Hispanics and minorities and that of the Hispanic community that denigrates gays in their ranks.

Being denied access to mainstream occupations results in unawareness of availability of services, products, and ways to access them. This factor needs to be taken into account in the design of an intervention. To advise someone from a deprived socioeconomic level to "use condoms with Nonoxynol 9 lubricant" does not take into account the myriad of difficulties the person will encounter following the advice, not the least of which is knowing how to obtain the money to buy them. Making condoms available for free to the target population may have a much better chance of success.

IMMIGRATION STATUS

Many gay Hispanic men in the United States are recent immigrants who left their countries of origin because of governmental policies of persecution and repression of gays. Some of these immigrants are illegal. These factors may prevent them from consulting health agencies or seeking counseling about AIDS because of fear of deportation. With this in mind, outreach efforts directed to the Hispanic community should make it clear that no report to immigration authorities will be involved.

Case Study

Nicomedes was an illegal alien who was a native of Ecuador and had come to New York lured by histories of sexual freedom. He consulted an outpatient AIDS clinic in a general hospital when the KS (Kaposi Sarcoma) lesions in his feet became too painful for him to continue working as a bus boy in a restaurant. During group psychotherapy sessions he informed us that he had noticed the lesions several months before the first consultation. He neglected seeing a physician, however, because he was afraid of deportation.

SOCIAL STRUCTURE AND VALUES

As I was growing up in Argentina, each government course I took started with the phrase "The family is the basic unit of society." Indeed, most Latin-American cultures place a strong emphasis on the importance of the family. This concept encompasses much more than the immediate family. Grandparents are considered an integral and important part of the family (there is strong resistance, for example, to place incapacitated grandparents in nursing homes). Aunts, uncles, their children, and even more distant relatives are also considered part of what is known as the "extended family." Then there are the compadres and comadres, people very close to the family, because they are the godparents of a child, because they come from the same hometown, or simply because they are good old friends.

This family system has its positive and negative aspects. On the positive side, family ties tend to be very strong and there is always a family member available to offer help in times of need. On the negative side, this structure often interferes with privacy. All family members know the business of everybody else and feel entitled to make their opinions known. It is not unusual for relatives of young gay Hispanic men to haunt them with questions and commentaries about girlfriends or marriage plans. A gay Hispanic man may feel that it is a lack of respect toward a family member not to answer such questions, and he

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may resort to evasive answers that, in the end, make him feel badly about himself.

Case Study

One of my HIV-positive clients had a male lover for 12 years but kept it a secret from his family. Whenever they asked about the reason for his being a bachelor in his mid-30s, he responded that he had not yet met the right woman. This resulted in active involvement on the part of the family to introduce him to available women that, in turn, resulted in anxiety attacks for the client.

Even in cases when the homosexual orientation of a family member is clearly known, there may be power struggles between the family and the lover. The following is an example:

Jose, 25, and Julio, 21, a Hispanic gay couple who had been together for 3 years, had both contracted AIDS. They extensively discussed in psychotherapy their feelings about the disease before breaking the news to Jose's family, with whom they lived. After the initial shock, Jose's mother said she would bury Jose in Puerto Rico, whereas Julio had expected both of them to be buried together in New York. Although Julio felt heartbroken about "having lived all these years together and then being separated at the end," he did not dare confront Jose's mother. "She is a mother, and she is Hispanic; you don't argue with her about where her son will be buried."

A counselor may help a gay Hispanic client to determine whether he wishes to "come out" to his family and tell them about his sexual orientation or whether he prefers not to discuss the issue. In any case, the client may practice with the counselor, through modeling and role playing, the kind of responses he could give to intrusive questions of relatives to preserve his privacy and at the same time maintain a cordial and respectful attitude toward his family members.

Respeto (respect) is a serious consideration that regulates many social interactions. Hispanics may seem timid or very submissive in their treatment of the elderly or authority figures. This was called power distance by Hofstede (1980). In the Hispanic community, this behavior is a sign of decorum. A visit to "the doctor" is also colored by this value system. Dressed in Sunday clothes and with shoes impeccably polished, Hispanic clients explain their problems in a candid way, apologizing for not knowing polite words to refer to parts of their bodies or to explain dysfunctions. When it comes to disclosure of homosexual activity, feelings of embarrassment may lead clients to try to excuse their behavior.

Case Study

A 37-year-old male Hispanic involved in a long-standing relationship with another man had developed a perianal rash. He felt the need to "tell the truth" to his physician about his sexual practices but felt very uncomfortable doing so, especially because "the physician was Hispanic as well." He finally decided to justify his sexual behavior by telling the professional that, to get a promotion in his job, he had accepted the advances of a gay male manager. This excuse seemed more acceptable to him than admitting that he had been in love with a man for more than a decade.

A respectful approach to the doctor may interfere with open disclosure but may be favorable for certain counseling

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modalities. Gay affirmative interventions and role modeling may at times be quite effective with gay Hispanic clients in teaching them, for example, how to negotiate the use of condoms.

The social structure also plays an important role in Hispanics' deep concern about "qué dirán?" (what will people say?). Gay Hispanics at times sacrifice being in the company of a loved one or enjoying themselves in gay environments just out of fear of being seen and having to face unfavorable comments. The following is an example:

A prestigious Hispanic physician who had worked extensively in AIDS prevention recently died in this city. Despite his notoriety in the field, the family refused to have the obituaries mention that he died of AIDS; they were concerned about "qué dirán?"

This fear of social judgment is many times resistant to change. An empathic and nonjudgmental therapist, however, may provide the client with the positive experience of being accepted as he is. This may increase self-confidence and, to a certain degree, diminish preoccupation with "qué dirán?"

In traditional Hispanic society, the sexual roles of men and women are clearly defined. Men must be macho, women must be pure. Men are expected to have a sexual debut at a young age and to maintain a fairly promiscuous sexual behavior through life. A man who has an opportunity of a sexual encounter must not overlook it, or he will risk being considered dumb. Sexual urges of men are reputed to be very difficult to control and require periodic "discharge." Within this logic it is many times "forgiven" that a macho man reputed to be heterosexual may use a maricón (faggot) to satisfy his sexual urges. Bakeman et al. (1987) reported that the percentage of bisexual men among AIDS cases is 1.5 greater for Hispanics than for WAA. These are important factors when it comes to assessment of risk behavior for AIDS and counseling approaches. Despite having sex with men, a Hispanic man may not identify himself as being gay or bisexual as long as he can justify that his sexual urges drove him to satisfy himself in whatever way was available. Marin (1988) reported that many Hispanic men who have sexual relations with other men may reject or discount messages targeted specifically to homosexuals. Therefore, a counselor should be careful about labeling a Hispanic man as gay or bisexual at the risk of alienating him.

There also seem to be differences in the sexual behavior of gay Hispanic men when compared to WAA. In contrast to the anecdotal bigger popularity of oral sex among the latter, many Hispanics feel that there must be penetration for sexual intercourse to be satisfying. In such cases it may be more difficult to encourage gay Hispanic men to engage in mutual masturbation or other nonrisky sexual activity than to concentrate the intervention on the correct use of condoms. Marin, Marin, and Juarez (1988) have stated that, in open-ended questioning, when asked what might be used instead of penetration, no Hispanic out of a sample of 119 mentioned mutual masturba-

tion.

RELIGION AND FOLK BELIEFS

There are other important factors to be considered in the counseling of gay Hispanic men. Religion and folk beliefs can play a significant role.

Catholicism is widespread among Hispanics and strongly influences the culture. This religion, based on conservative and traditional values, strongly rejects gay life-styles (Suro, 1988).

Hispanic Gay Male AIDS

Pope John Paul II has actively condemned homosexuality, and because the Pope, at the head of the church hierarchy, is considered infallible and in communication with God, his condemnation brings guilt and anxiety to many Catholic gay people. Cardinal O'Connor, in New York City, also banned gays from attending religious services as an organized group. These types of attitudes many times alienate Hispanic gays, who consider religion an important and integral part of their lives. In a counseling context it is important not to overlook the importance that religion has for the client. If the client only engages in furtive sex because of his guilty feelings about homosexuality (Malyon, 1982), the counselor may need to work on those feelings before any behavioral change can be suggested to prevent infection. These interventions should not, however, attack the religious beliefs of the client, which may be deeply rooted.

Santeria is a widespread folk belief among east coast Hispanics. Its roots can be traced to ancient Yoruba rituals brought by Africans to the Caribbean during the decades of slave trade (Gonzalez-Wippler, 1989; Pasquali, 1986). Yoruba rituals and beliefs were proscribed by the ruling Catholic church, but the believers disguised the old African deities, giving them names of saints (hence the name santeria). Under this cover, rituals and beliefs persisted. Many New York Hispanics of Caribbean origin either strongly believe in Santeria or keep a respectful distance from it.

Espiritismo (Spiritism) is also quite popular among Hispanics (Schwartz, 1985). Mediums are able to invoke certain spirits at the request of a sufferer. The spirit of dead people is said to return to offer advice and guidance to the living.

During psychotherapy, clients generally do not discuss their religious folk beliefs out of fear of not being taken seriously. Therefore, when counseling gay Hispanic men counselors should tactfully but actively explore these beliefs. In times of despair, when medicine can offer no solution to pain and suffering, spirituality may be quite comforting to the client. At times, spiritists' rituals can be used as a form of psychodrama (Seda Bonilla, 1969). On the other hand, if the client refuses to follow safer sex guidelines, believing that he is protected from infection by a certain spiritual force, this conviction should be challenged.

CONCLUSION

Many of the factors described above apply not only to gay Hispanic men but also to other minority populations as well. Nevertheless, in the counseling or treatment of gay Hispanic men, careful attention to these variables will improve the communication and result in more effective interventions.

It is undoubtedly helpful for a Hispanic client undergoing psychotherapy or counseling to work with a bilingual-bicultural professional. If the professional is also attuned to and nonjudgmental of gay life-styles, discussion of pressing issues for gay people, such as the AIDS epidemic and its consequences, will be highly facilitated. The client will tend to open up much more and to develop quickly a feeling that there is an empathic understanding of his situation.

In areas of the country where bilingual-bicultural professionals are not available, people from the Hispanic gay community may be trained to act as liaisons between the professionals and the community. With careful training on the ABCs of counseling plus close professional supervision, many gay men with leadership skills may become excellent facilitators of group discussions on AIDS and related issues.

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